The Case of the Missing Explanation of Benefits

“Guess this is from my preventive visit in January?” she said with a shrug.

Somewhere on the bill, it did say the bill ‘Reference Laboratory Services’, but there was no itemization so we couldn’t be sure what service was performed.

“Did we get an EOB?” I asked my wife.

“I don’t think so,” she said.

An EOB is an “Explanation of Benefits” and is more commonly recognized as that piece of paper which says “This is NOT a bill.” More usefully, an EOB is the informational result of an insurance company running a claim submitted by a service provider, be it a doctor, a hospital, a lab, etcetera.

After confirming that there was no EOB, either in our hard copy files or available on our insurance company’s website portal, I decided to take action. The only option offered on the bill for service assistance was a phone number, which I consider odd in this day-and-age of technology. So, I posted the bill on social media with a note.

“You can do better,” I wrote, tagging the service provider.

To their credit, they responded that same day and called me the next morning. We discussed the possibility that my insurance information was not available, and/or the possibility that there was simply a mistake in filing. I conceded that these explanations, theoretically, were possible.

I also explained that we’d been to the same office many times, with the same insurance. There had been no changes to our card or insurance information. So, why the mistake?

Here’s the thing: I worry about the routineness of an issue like this. I’ve seen it more than once, and often with people who can afford $50 less than I can afford several hundred. Recently, when talking to a group of nearly 100 medical students and asking them how many had faced something similar…almost all raised their hands.

At the core, it’s at worst a $0.50 bet (the cost of stamp) by a service provider that the recipient will simply pay the bill and avoid a hassle. Which is generally a good bet. Because, if filed as a claim against insurance, the service provider—instead of getting several hundred dollars—might only get, say, $20. (Yes, the discrepancy could be that wide.)

So please remember that ANY medical service you seek out—if it’s filed appropriately through your insurance—should result in an EOB explaining the cost before you get any bills. If you don’t recall getting an EOB…STOP. Do some research. And, perhaps, make some noise on your own behalf before assuming everything is correct and simply paying.

Hopefully, this sort of ‘mistake’ becomes a lot less common in the future.

About the Expert

Pediatrician Dr. Bryan Fine has been a physician for more than 15 years, and is the founder of Percentric, an innovative, physician-led health benefits optimizer. Visit Percentric.com to learn more.